Received: 11 July 2018 | Accepted: 11 September 2018 DOI: 10.1002/nau.23851

SOUNDING BOARD

Obstetric : The role of physiotherapy: A report from the Physiotherapy Committee of the International Continence Society

Gill Brook MCSP (DSA)CSP, MSc | The ICS Physiotherapy Committee

International Organization of Physical Therapists in Women's Health, Burras Aims: To discuss the role of physiotherapy in the management of women who have Lynd, Otley, West Yorkshire, United suffered an obstetric fistula, referring to research findings when appropriate and Kingdom available, and the experiences of clinical specialists in the field. Correspondence Methods: The experiences of physiotherapists who have worked in countries where Gill Brook, Burras Lynd, Burras Lane, obstetric fistula is prevalent, and the limited literature available, were considered in Otley, West Yorkshire, LS21 3ET, United producing this consensus document on behalf of the ICS Physiotherapy Committee. Kingdom. Email: [email protected] Results: The role of physiotherapy both pre- and post-fistula repair was identified, and is multi-faceted. Women may have general rehabilitation needs based on the obstructed labor itself and subsequent care. All affected women may benefit from pelvic floor muscle assessment, education and exercises to optimize the outcome of their surgery; further pelvic floor physiotherapy may be indicated for those who experience persistent genitourinary dysfunction following closure of the fistula. Conclusions: Further robust research is required to confirm the effectiveness of physiotherapy in the management of women who have suffered an obstetric fistula and the optimum development of such services. Based on the available literature and the experience of physiotherapists in the field, there was consensus within the ICS Physiotherapy Committee that patient outcomes can be improved if physiotherapy is provided as part of the multidisciplinary team. Physiotherapy should not be overlooked when fistula services are being developed.

KEYWORDS physiotherapy, ,

1 | INTRODUCTION fistula as a result of obstructed labor each year while several million women live with the effects of the injury.1 Although accurate figures are not available, it has been The role of physiotherapy in the management of women estimated that 50 000-100 000 women develop an obstetric who have suffered an obstetric fistula (OF) has been recognized by previous authors.2–4 A physiotherapist brings

Diane Newman led the peer-review process as the Associate Editor specific knowledge and skills, contributing to quality of care responsible for the paper. and optimum outcomes. This paper will discuss the role of physiotherapy, referring to research findings when appropri- In line with the journal's guidance on Author Contributions, members of the ICS Physiotherapy Committee who commented on the draft document ate and available, and the experiences of clinical specialists in are listed in the Acknowledgments section. the field (see Acknowledgments). It will be neither an

Neurourology and Urodynamics. 2019;38:407–416. wileyonlinelibrary.com/journal/nau © 2018 Wiley Periodicals, Inc. | 407 408 | BROOK exhaustive list of services, nor prescriptive, but should offer compensatory adaptation. There were no recommendations an overview of current and potential physiotherapy provision. on physiotherapy to address these findings, but a treatment The role will be discussed in terms of general rehabilitation, program can be developed to meet the specific needs of the and specific pelvic floor physiotherapy. woman with focus on recovery of her ability to carry out the activities of daily living necessary for post-operative 2 | ROUTINE PHYSIOTHERAPY reintegration into her community. ASSESSMENT 3.2 | General weakness Physiotherapy assessment (Appendix 1) may be undertaken As a result of prolonged immobility, with resultant muscle pre- or post-repair and should be patient specific.2 atrophy ± poor nutrition and comorbidities, women can experience general weakness and deconditioning. The goals 3 | GENERAL PHYSICAL of physiotherapy will be to improve muscle strength and REHABILITATION function, exercise tolerance, mobility, and ability to under- take activities of daily living. Although some women will present in relatively good general For women with such physical rehabilitation needs it is health, in countries where OF is prevalent, others may be difficult to accurately predict how long recovery will take or experiencing general weakness, walking difficulties, foot how complete it will be, particularly in the case of foot drop or drop, or joint contractures. These may be associated with the contracture. It is not an area that has been researched to date. obstructed labor itself or management during the postnatal Whereas a woman with simple foot drop may be fit for period when it is not uncommon for women to lie down for surgery and subsequent discharge very quickly (albeit with an prolonged periods in the hope that their incontinence will altered gait if the loss of ankle dorsiflexion does not resolve), stop. Timely physiotherapy is indicated to address these a woman with marked joint contractures may require many dysfunctions. months of treatment both pre- and post-operatively. Although pre-operative rehabilitation may help ensure 3.1 | Foot drop and contractures that a woman is fit to go home soon after surgery, there are undoubtedly women who will benefit from physiotherapy Foot drop has been reported in up to 30% of women following post-operatively to enhance their physical recovery. OF in Ethiopia5 with both a lower6 and higher7 incidence noted elsewhere. If left unattended, and compounded by a 3.3 | Group exercises lack of mobilization, it can result in not only ankle but other lower limb joint contractures. It is probably due to While some treatments will require one-to-one attention from compression of the lumbosacral nerve trunk within the the physiotherapist, much can be undertaken satisfactorily in during the obstructed labor, or peroneal nerve injury related to a group of women with similar impairments and rehabilitation prolonged squatting.8 Foot drop may vary from “simple” (no needs. This is not only an efficient and cost-effective use of a tightness of the Achilles tendon and full passive dorsiflexion) healthcare professional's time, but also an opportunity for through to “severe” where passive dorsiflexion is severely women to meet other patients—possibly at different stages of limited, and the woman may walk on her toes. The goals of recovery—and share common experiences and concerns. physiotherapy will be to prevent or reduce joint contracture, Exercise interventions will depend very much on the facilitate muscle activity, enable independent mobility, and rehabilitation needs and physical capabilities of the women independence in activities of daily living. In complex cases, concerned, facilities, and the equipment available, plus the and subject to availability, serial casting or even surgery may knowledge and skills of the clinicians involved. An exercise be needed if more conservative measures fail. program should be developed with consideration of the Functional electrical stimulation (FES) has been used in available evidence and best practice at the time. It may be the management of foot drop for many years and has been appropriate to include warm-up and stretch, posture correc- shown to be both effective and preferred by some patients tion, and a range of exercises that could include medium level (following stroke) when compared to use of an orthosis.9 aerobic, balance, muscle strengthening, mobility, and However, it may not be an option due to a lack of equipment functional activities. or suitably skilled staff. 6 Tennfjord et al found that walking difficulties were 3.4 | Activities of daily living common in women with OF, who demonstrated decreased ankle and knee range of movement, but increased Physiotherapy should always consider the needs of the hip movement and muscle strength, possibly due to individual, including their social circumstances. In BROOK | 409 countries where OF is prevalent, many women undertake A voluntary PFM contraction just before and during a heavy work on a daily basis at home and in employment, so cough, referred to as “The Knack,”15 has been shown to rehabilitation should integrate appropriate functional activ- reduce leakage significantly in women with stress urinary ities such as lifting and carrying. Women who have suffered incontinence. It might also be prudent to teach “The Knack”15 an OF will almost inevitably have sub-optimal function of to women following OF; with coughing, other increases in their pelvic floor and associated muscles in addition to any intra-abdominal pressure, and with urinary urgency, to of the impairments previously described. Therefore the minimize the risk of leakage and reduce pressure on the importance of correct body mechanics should be empha- pelvic floor. sized to optimize recovery, facilitate a return to normal In addition to PFME, Castille et al10 advised women on activities, and reduce the risk of further injury or measures to reduce pressure on their pelvic floor and repair dysfunction. site, with posters on display within the healthcare facility to reinforce this message. The poster included diagrams of tasks which should be avoided and a good lifting technique among 4 | PELVIC FLOOR other pictorial advice. This is a potentially useful measure in PHYSIOTHERAPY any center where women with OF are treated.

Women who have suffered an OF may benefit from pelvic 5 | RECTO-VAGINAL FISTULA floor assessment, advice, and treatment (if required) before undergoing surgical repair. Research has indicated that there In a study of 14 928 Ethiopian women with OF, 13.5% had a can be an improved outcome of surgery both in terms of recto-vaginal defect.16 The vast majority had also suffered a successful closure of a vesicovaginal fistula and reduced risk uro-vaginal fistula. Therefore, physiotherapists working in of persistent urinary incontinence10 if women are taught a this field will encounter women who are experiencing not correct pelvic floor muscle (PFM) contraction and advised to only , but also loss of stool. A digital practice pelvic floor muscle exercises (PFME). Other anorectal examination may be indicated, to assess not only the researchers11 have recommended pre-operative assessment pelvic floor muscles but also external anal sphincter function, although most of their study population were first seen and to advise on appropriate exercises. As with persistent following fistula repair. urinary incontinence post-repair of a vesico-vaginal fistula, PFME should be preceded by a digital vaginal examina- physiotherapy should be offered to women with persistent tion to ensure that the correct muscles are being contracted.10 anal incontinence following repair of their recto-vaginal There are no standardized instructions on how a PFM defect. Exercises and adjunct modalities such as biofeedback contraction should be taught but researchers have suggested12 or neuromuscular stimulation (if indicated and available) may that a directive to tighten as if stopping the escape of wind be appropriate. (gas), ± as if to hold in urine, produces the correct action. During examination, the clinician can also assess PFM function more extensively (eg, tone, relaxation) plus the 6 | EARLY POST-OPERATIVE condition of the and surrounding structures. The PHYSIOTHERAPY anatomy and tissues may look and feel very different from those of women previously examined by physiotherapists Although post-operative care may vary from center to center, who work in countries where obstructed labor is never or early mobilization is common practice, minimizing the risk of rarely allowed to progress. It may be difficult or impossible to respiratory and circulatory complications related to prolonged feel or identify some structures. This can be dependent on the bed rest. Women who are not able to mobilize within the first site and extent of the fistula, plus the length of time which has few days post-operatively may benefit from physiotherapy elapsed since the injury occurred. Digital anorectal examina- including appropriate positioning in bed and lower limb tion may be indicated, particularly if the vagina is very exercises. Following abdominal surgery physiotherapy may scarred. be required to prevent impaired lung function and retention of There is no universally agreed optimum regime for secretions. In relation to existing musculoskeletal dysfunc- PFME.13 In studies of an OF population, Keyser et al11 used tions, it should be possible to continue with much of the the PERFECT assessment tool14 and advised on a personal- physiotherapy started pre-operatively. ized exercise regime. Castille et al10 advised on 5 s If women experience constipation, possibly as a result of contractions, carried out for 10 min twice a day. Another post-operative dietary modification and immobility, then author2 suggested women exercise within their own capabil- abdominal massage may help stimulate peristalsis and ity, increasing the length of hold and number of repetitions as increase frequency of bowel movements, in addition to muscle strength improved. advice on an adequate diet and fluid intake. It is easily taught 410 | BROOK and no adverse side-effects have been reported.17 In the case hands-on soft tissue therapy may also be appropriate if the of complex fistula surgery, it would be prudent to seek the physiotherapist concerned is sufficiently skilled. opinion of the fistula surgeon if massage is considered within In many countries adjunct therapies such as biofeedback the early days post repair. or neuromuscular stimulation are offered to some women in In the absence of any evidence in support or against the re- addition to PFMT. A digital vaginal examination and verbal introduction of PFME post-operatively with a urinary catheter encouragement is a simple form of feedback that should be in situ, practice will be determined by the opinion of local widely or universally available to women who give their medical and physiotherapy staff. consent. Beyond that, biofeedback comes in many forms as does neuromuscular electrical stimulation. There are un- doubtedly barriers to the use of such equipment in the 7 | PERSISTENT URINARY countries where OF is most prevalent. Equipment and DYSFUNCTION consumables may be prohibitively expensive, if they are even available. Infection control and essential maintenance Despite successful repair of vesico-vaginal fistula in up to are additional challenges. Even if these barriers can be 95% of women18 a considerable number will experience overcome, any form of intravaginal treatment will be persistent urinary incontinence.3,19 It may be difficult to unsuitable for a considerable number of women because of differentiate between different types of incontinence because a lack of capacity within the vagina. of the complexity of the patient's condition and the frequent Many women have a reduced bladder capacity following lack of access to investigations such as urodynamics. repair of their vesico-vaginal fistula.20 This may well result in However, it is likely that any can occur.20 The lack of a urinary frequency, increased bladder sensation, and/or differential diagnosis is no barrier to physiotherapy assess- urinary urgency, which may be accompanied by incontinence. ment and treatment. The medical team concerned may offer guidance on prompted Pelvic floor muscle training (PFMT) is recommended as a voiding following removal of the catheter post-operatively first line intervention in the management of women with and this should be respected. Bladder training has been urinary incontinence.13 Arguably, it might be less effective recommended as first line management of urgency or mixed with women following vesico-vaginal fistula because of urinary incontinence13 although there is an absence of severe damage to the continence mechanism suffered as a evidence to demonstrate its effectiveness with this patient result of their obstructed labor.21 However, Dietz et al,22 in a population. Advice can be given on deferment of micturition study of 95 women in Addis Ababa before or shortly after in small increments in order to increase the bladder's vesico-vaginal fistula repair, found that PFM anatomy and functional capacity to a point where it has less of a major function was no more likely to be abnormal than in a general impact on a woman's lifestyle.2,11 Suppression of micturition, urogynaecological population. Ninety-one of the 95 women for example, sitting down or standing still, distraction, manual were able to contract the muscles voluntarily, suggesting that pressure on the perineum, or a PFM contraction2,11 might be PFMT is feasible. Two recent studies showed a positive effect advised and guidance on appropriate fluid intake given. from pre- and post-operative physiotherapy in terms of the Within developed countries, symptoms of an overactive incidence of post-operative urinary incontinence10 and bladder are commonly assessed by completion of a bladder improved PFM strength and endurance with a reduction of diary completed over a minimum of 3 days.24 In some incontinence in more than 70% of those undergoing countries where OF occur, these are unlikely to be practical, in treatment.11 In one follow-up study, improvement was part due to low literacy levels. A simple method whereby maintained at 1 year with a significant improvement in women tear off a piece of paper and place it in an envelope quality of life scores.23 (supplied to them for that purpose) each time they pass urine PFMT has previously been described and should be has been described as a useful alternative26 although it strongly encouraged with women experiencing persistent provides less detail than a measured input/output chart. urinary incontinence following their fistula repair. It should If there is evidence, or even a suspicion of incomplete be preceded by a digital vaginal examination with attention to bladder emptying (which can in turn contribute to urinary the anatomy of the lower genito-urinary tract which will frequency and urgency), women can be advised on double or probably have changed significantly following surgery. A triple voiding which may result in more complete bladder minimum of 3 months PFMT has been recommended in a emptying.11 Intermittent self-catheterization may be appro- general population.24 It has been suggested that supervised priate, taught by a suitably skilled clinician. training13,24 or more sessions with a healthcare professional25 Some women will undoubtedly remain incontinent. are beneficial but this may be impractical in many settings Intravaginal continence devices may be unsuitable for where women have traveled far to seek treatment and wish many; therefore, it is essential that low cost, accessible to go home at the earliest possible opportunity. Internal containment products are available locally to improve the BROOK | 411 quality of life of those affected; a need that has been Back pain is a common complaint in many populations, recognized and prioritized by the World Health and pregnancy-related lumbopelvic pain has been de- Organization.27 scribed by many authors. It has been reported that as many Despite persistent urinary symptoms, it is likely that many as one in five women will still be experiencing women will return home following surgery if they are lumbopelvic pain 2-3 years after .29 So, it is otherwise well. Reviewing a group of women at a 6-month no surprise that some women who have suffered an OF will follow-up, Browning and Menber28 reported a trend for those complain of back or pelvic girdle pain, which may or may who were incontinent at discharge to improve over time. not be directly related to obstructed labor and the Castille et al10 followed up women (using local nurses) at 3, 6, intervening period before they present for treatment. A and 12 months but this would undoubtedly be a logistic and comprehensive, evidenced-based and best practice phys- financial challenge in some countries. It is good practice to iotherapy assessment should ensure that appropriate encourage post-operative follow-up to assess the long-term treatment can be offered based on the clinician's outcomes of fistula surgery, and physiotherapy should be knowledge and skills. It is important to include assessment available for those women with persistent urinary or of any divarication/diastasis of recti abdominis which musculoskeletal dysfunctions. should be addressed with appropriate exercises to maxi- Inevitably, there will be women with intractable, severe mize the chance of recovery. urinary dysfunctions which require more invasive manage- Severe vaginal scarring has been identified as a risk ment. If a continence procedure is to be undertaken, then pre- factor for failure of closure of vesico-vaginal fistula, and and post-operative advice on PFM training may help residual urinary incontinence.18,30 These women may be maximize the benefit of surgery. For some women, urinary those commonly seen by a physiotherapist post-opera- diversion might be offered; for example, Mainz II pouch, tively when they have persistent leakage. In addition, there whereby urine is redirected to the lower digestive tract and are likely to be women with an altered vagina (related to ultimately passed per rectum. For this procedure to render the obstructed labor or repair) who are continent but report patient continent, it is essential that she has sufficient PFM vaginal pain and/or . A suitably skilled and external anal sphincter strength and endurance otherwise physiotherapist can offer a range of internal hands-on leakage will persistent. Once more, pre-operative pelvic floor soft tissue therapy which some women may be willing and muscle/external anal sphincter assessment and treatment are able to continue themselves to enhance their recovery. Pain indicated. or anticipated pain may result in poor relaxation of the PFM, hypertonicity, or . Hypertonicity, in turn, is a significant component in sexual pain disorders.31 8 | PAIN Therefore, pelvic floor re-education with an emphasis on relaxation is indicated for at least some of these women. Although the principal concern of a woman who has suffered Within some countries vaginal dilators are used for the an OF may be incontinence, the nature of her injury and its treatment of vaginal scarring, for example, following sequelae can result in pain and this should not be ignored. radiation, and are also offered to women with vulvar pain. 6 Tennfjord et al reported an incidence of leg pain A small study into the latter32 showed some positive following obstructed labor and obstetric fistula in 20% of outcomes, as part of a larger package of treatment. Vaginal the women they assessed versus 7% in a control group. The dilators may, therefore, be an additional treatment choice authors reported spontaneous recovery in less than a third. for women with vaginal scarring, abnormal pelvic floor The cause of such lower limb pain may be multifactorial. muscle activity or pain in the area, if they are available. Some cases will be due to neurological effects of the labor itself, while others may be related to a period of immobility afterwards, resulting in a loss of function in the lower limbs, 9 | OTHER ROLES with or without joint contractures. In some cases, a compensatory increase in movement of certain joints has Although there are physiotherapy teams within some fistula been found,6 possibly to facilitate ambulation. In practice centers, it is unlikely that they are as prevalent, or as well within fistula centers, physiotherapists have reported in- resourced, as physiotherapy departments in hospitals else- cidents of leg pain which is elicited or exacerbated by a where in the world. So, in addition to the interventions already change of position from lying to sitting or standing, described (Table 1) some clinicians.10,11 describe a role for suggestive of a vascular cause. Treatment for leg pain should visiting physiotherapists in the education of not only local include adequate, appropriate medication as required, general physiotherapists, but also nurses and other hospital staff. care provided by a fistula center and appropriate Physiotherapists working within fistula centers can learn from physiotherapy. the doctors and nurses assessing and caring for women and, in 412 | BROOK

TABLE 1 Physiotherapy intervention Appropriate assessment (see Appendix 1) Before fistula repair surgery After fistula repair surgery Pelvic floor muscle education & exercises Address any early post‐operative concerns: • respiratory dysfunction • decreased mobility • constipation • pain management Rehabilitation for any general weakness, Continue with rehabilitation for any persistent general weakness, foot drop, or contractures foot drop, or contractures Appropriate pain management if indicated Persistent urinary, anorectal or pelvic floor dysfunction—reassess and treat Discharge or review postoperatively if Surgery for persistent incontinence—advise and treat pre‐ and post‐operatively required

exchange, share their own particular skills. This includes the means to ensure that relevant advice reaches the women identification of pelvic floor muscle hypotonicity, hyperto- concerned. nicity, as well as the ability to contract the muscles correctly and PFME. In the case of fistula centers with no resident 10 | CHALLENGES physiotherapy team this should be seen as the principal role of any visiting staff, to contribute to a sustainable, quality There are, undoubtedly, major challenges (Table 2) facing service for the patients. It is recognized that the conservative physiotherapists working with women following OF in the management of pelvic floor dysfunction may be provided by a countries where they are most prevalent. These should be range of clinicians but cannot then be termed “physiotherapy” recognized and, where possible, addressed. since this may only be provided by a registered It is quite likely that there will be few funds available to physiotherapist.33 buy equipment and consumables which are normally With increasing availability of the Internet worldwide it available within physiotherapy departments. There will often is becoming easier for overseas physiotherapists to maintain be no department, nor even a dedicated area in which contact with, and offer ongoing support to, staff within physiotherapy can be carried out. However, this need not stop fistula centers. However, the view of clinicians who have delivery of a quality service. contributed to this paper is that distance learning and Language will almost inevitably be a challenge for any support, useful as they are, should not take the place of non-native physiotherapist. Although some exercises can be regular visits. taught by demonstration, a comprehensive subjective and Some women who have previously suffered an OF will objective assessment cannot be completed satisfactorily go on to have another pregnancy. In a study of 240 women at 6-month follow-up after fistula repair,28 6were pregnant. Nielsen et al34 found 4 of 38 women reviewed at 14-28 months post-repair had been pregnant in the TABLE 2 Challenges interim period. It is unlikely that many, if any, physi- Personnel Lack of physiotherapists otherapists will have regular contact with these women Lack of specialist education throughout their pregnancy. However, since the women are Financial Staff salaries encouraged to present at a suitable healthcare center before constraints Equipment the end of their pregnancy ahead of an elective Caesarean Consumables section, there may be an opportunity to see them at that Training stage for appropriate advice and treatment. Physiothera- Facilities Department pists should also take any opportunity to liaise with local Treatment space with adequate privacy midwives, or other healthcare staff in contact with Communication Language pregnant women, so that they can incorporate appropriate Literacy advice into their antenatal checks and refer women to Religion & Understanding (eg, in relation to anatomy, physiotherapy if such a local service exists. If physiother- culture pathophysiology) Sensitivities (eg, vaginal examination) apy input into midwifery training schools is available and welcomed, then this is an efficient and comprehensive Evidence base Limited research and clinical audit evidence BROOK | 413 unless there is someone present to translate. In the absence of such assistance it is also impossible to adequately explain the Executive summary process of digital vaginal examination, address any patient concerns, and obtain valid and informed consent, without • Pelvic floor physiotherapy offered pre- and/or post- which many physiotherapists are not permitted to proceed fistula repair may improve outcomes in terms of with an intimate examination.35 urinary and and should include In a large study of women who had suffered an obstetric specific advice on bladder and bowel care in addition fistula,16 77.4% were illiterate; a far higher level than that to pelvic floor muscle training to optimize outcome. found in many countries. Therefore, physiotherapists cannot • Women who have suffered an obstetric fistula may rely on the written word for most patients, and must ensure present with a range of significant musculoskeletal that any information they are relaying is explained clearly dysfunctions including foot drop and soft tissue and simply, checking regularly that it has been understood. contractures. Where visiting physiotherapists are training local physi- • Physiotherapists have an important role in otherapists and other hospital staff, it is equally important to optimizing general health and addressing rehabilita- ensure that education is delivered at a suitable level for the tion needs before and after fistula repair, to aid individuals concerned. In particular, they should understand recovery. the level and nature of physiotherapy education in that • The role of physiotherapy should not be overlooked country. when fistula services are being developed. It should go without saying that any physiotherapist • Robust research is required to confirm the impact visiting a fistula center in a different country must be aware of and role of physiotherapy with this patient group, religious and cultural factors which might impact on their particularly in countries where obstetric fistula is still interaction with patients and staff. prevalent.

11 | OUTCOME MEASURES AND FUTURE RESEARCH 12 | CONCLUSION With the exception of a few authors,11,10 there is little research that supports the role of physiotherapy in the This paper highlights a lack of evidence for the role of management of women who have suffered an OF. Further physiotherapy in the management of women with OF. robust evaluation of our interventions is indicated on the However, there was consensus within the ICS Physiotherapy role of pelvic floor education and PFM rehabilitation for all Committee, some of whom have experience in treating women who have suffered OF; the specific management of affected women, that patient recovery, clinical outcomes, and persistent urinary symptoms after successful repair; plus the quality of life can be improved if physiotherapy is provided as broader rehabilitation of women with related musculoskel- part of the multidisciplinary team. Further robust research is etal dysfunctions. required to confirm the effectiveness of physiotherapy in the In addition to controlled trials, it is also useful for management of these women and the optimum development therapists to audit their service, in which case outcome of such services. measures are essential. As described earlier, some use a pelvic floor muscle assessment tool14 at initial assessment, and this ACKNOWLEDGMENTS can be repeated at discharge to evaluate any benefit.11 The same authors used the Addis Ababa Fistula Hospital Thank you to the following physiotherapists/physical incontinence scale3 to measure the effect of their intervention. therapists for sharing their experiences of working with Castille et al10 preferred the Ditrovie scale,36 a French women who have suffered an obstetric fistula; their language continence quality of life tool. Although not contributions are greatly appreciated: Yves Castille, Lesley reported with this population, the ICIQ-UI Short Form is a Cochrane, Heather Enns, Loran Hollander, Laura Keyser, simple questionnaire that assesses the impact of symptoms of Michelle Pieké, Jessica McKinney, Tracy Spitznagle, and incontinence on quality of life37 and it, too, may be of use as Merete Tennfjord. Also to the ICS Physiotherapy Committee might a simple visual analogue scale. There are numerous for their comments and suggestions, especially Rhonda other tools which may be useful in the assessment of women Kotarinos, Doreen McClurg, Paula Igualada-Martinez, Petra with the range of complex dysfunctions associated with Voorham van der Zalm, and Rebekah Das. Particular thanks obstetric fistula, and measurement of the effect of physio- to the physiotherapy team at the Hamlin Addis Ababa Fistula therapy intervention. Hospital. 414 | BROOK

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APPENDIX 1  Functional activities, for example, squatting, lifting, carrying2,10,11 Routine physiotherapy assessment  Abdominal and perineal mobility, pain, scar tissue11  Researchers and clinicians have suggested the following Pelvic floor muscle (PFM) function: 2,4,11 inclusions, dependent on the patient's abilities and - digital vaginal ±anorectal examination 10 limitations: - manometric, electromyography, or other biofeedback - PFM, for example, strength, endurance, tone, 4,9,11  Subjective assessment (before physical examination) to relaxation  11 include presenting symptoms, for example, impaired Diaphragmatic breathing  10 mobility, loss of function, pain, bladder or bowel Pad test, volume passed on urination  dysfunction. Past medical history and social history should Subjective report of level of incontinence (most relevant be included unless previously undertaken and available. post-operatively), for example, Addis Ababa Fistula 3,11  Movement, for example, in bed, transfers2,11 Hospital score. Type of urinary incontinence, for  Gait analysis2,11 example, stress, urgency, or mixed.   Lower limb range of movement and muscle strength— Bladder diary (language and literacy dependent). looking for muscle weakness, foot drop, joint contractures2,6 Inevitably, assessment will be longer and more detailed  Spinal assessment for some women than for others. Pelvic floor muscle  Reflexes6 assessment is universally important and appropriate docu-  Pain—location, type2,11 mentation is essential.